Corneal transplant surgery and COVID-19

Robert L Wisse, MD, PhD Ophthalmologists and patients alike know that the COVID-19 pandemic is affecting the provision of all ophthalmic care. Speaking with EuroTimes, Robert L Wisse, MD, PhD, Head of the Utrecht Cornea Research Group at the University Medical Center Utrecht, The Netherlands, talked about its enormous consequences for corneal transplant surgery. Dr Wisse described the impact as the worst possible situation one could imagine. Yet, through the quick coordination of personnel, policies and protocols have been established to address the challenges. Summing up the current state of corneal transplant surgery in The Netherlands, Dr Wisse said that the most pressing matter is the lack of available donors suitable for corneal tissue donation. He explained, “Apart from the stringent restrictions that are in place regarding access to hospitals for the explantation teams, the risk of COVID-19 transmission to the graft recipient must be considered. The donor tissue supply has been acutely reduced to practically zero, and the surgical facilities and personnel are being reserved for only the most acute, sight-threatening cases. The majority of corneal transplant procedures are not urgent from a medical perspective, and they are now being postponed indefinitely.” Fast action Responding to the coronavirus crisis soon after its onset, the Dutch Transplant Foundation quickly established a routine to have twice weekly meetings. The participants, who include transplantation medicine specialists, heads of both cornea banks in The Netherlands, and the board members of the Dutch Corneal Society, share insights on emergency protocols and procedures. In addition, the group established a cornea hotline that would serve as a secure and private platform for discussions when a highly urgent surgery is anticipated. “We quickly realised that proper allocation of the few available grafts for the rare highly urgent cases would require intensive timely communication. Email correspondence was not efficient enough,” Dr Wisse said. “With the cornea hotline chatgroup, all Dutch corneal surgeons, the cornea banks, and the Transplant Foundation members collaborate to deliver the best possible care in these dire circumstances.” Tissue safety Dr Wisse pointed out that the group is working in uncharted territory, but dedication to assure patient safety remains paramount. Therefore, the decision was made to only accept tissue from donors proven negative for COVID-19. In addition to following international guidelines that assure procurement of the safest possible tissue, the process now incorporates extensive testing to ensure that donors are negative for COVID-19. As added safeguards, consideration is given to age of the donor and whether the individual died of pulmonary disease or resided in a COVID-19 high-risk area. “The guidelines are subject to weekly evaluation because the situation is evolving so rapidly,” Dr Wisse said. Emergency surgery Surgery is being done for patients with an emergency indication for a corneal transplant procedure. These are cases where there is otherwise certain loss of the eye or visual function, such as following major trauma or in the setting of refractory severe infectious keratitis. A daily national monitoring hotline was established for allocating the scarce donor material for these cases. “Fortunately, these urgent surgery cases are rare, and thanks to the excellent collaboration in our transplant chain, none has been cancelled or postponed,” Dr. Wisse said. COVID-19 status of the recipient is another issue that might need to be considered. Dr Wisse noted that in principle, surgery could still proceed if the recipient is considered at high risk for COVID-19 infection or even tests positive. “The possibility of encountering this situation may be remote because with the very high threshold in place for proceeding with surgery now, only the most severe cases are eligible. Should this hypothetical scenario arise, we would consult with our hospital infectious disease specialists about proceeding,” Dr Wisse said. Clinical care Ongoing patient care adheres to hospital protocols that have quickly been modified in response to the COVID-19 crisis. If a patient tests positive for the virus or shows signs of an active acute infection, consultations are taking place in dedicated coronavirus facilities with all necessary safety precautions. The crisis has also affected the ability to see post-transplant patients, and follow-up visits for these individuals have plummeted. Many of the follow-up appointments are being conducted remotely through teleconsultations supported with an online visual acuity test. “With this approach and critical shared decision making, we hope to reserve the available facilities for patients who duly need a clinic visit,” Dr Wisse said. Dr Wisse also observed the Dutch Cornea Patient Society (Hoornvlies Patienten Vereniging, https://oogvooru.nl) is playing a valuable role in keeping patients informed through its social media channels and mailings. “We have a very active collaboration with this group that is an association of patients for patients and that has a high representation of Dutch patients with corneal disease among its members,” he said. Future and final reflections Looking ahead to when the crisis is over, Dr Wisse raised concern about the need to address the backlog of patients waiting for transplant surgery. “It remains to be seen how many weeks or months it will be until we can even begin scheduling these elective procedures and subsequently how we will cope with the growing reservoir of deferred care,” Dr Wisse observed. He expressed his thanks and appreciation to all of those involved in developing policies and procedures for cornea transplant surgery in The Netherlands in response to the COVID-19 pandemic and said he is heartened by the collaborative spirit and effort of everyone. “These are difficult times, and we are all dedicated to make the best of it,” Dr Wisse said. He is also thinking about the patients whose lives are being impacted. “Importantly, my thoughts are with our patients who are the most important stakeholders in this process. The disruption to their care and uncertainty surrounding the situation must be frustrating and even frightening. Yet, every patient I have talked to on the phone has been understanding and sympathetic,” Dr Wisse said. He concluded, “I hope this message reaches everyone in good health.”